Schedule of Benefits

If you are unsure as to which plan applies to you and/or dependents, please call Member Services at 1-800-523-2846.

** All of the benefits noted on the following pages are subject to the eligibility schedule set forth in the Summary Plan Description

	Medical
	Horizon BCBS PPO PLATINUM	Horizon BCBS PPO GOLD	Aetna EPO PLATINUM	Aetna EPO GOLD
PCP Visit	$20 Copay	$30 Copay	$15 Copay	$25 Copay
Specialist Visit	$30 Copay	$40 Copay	$25 Copay	$35 Copay
Emergency	$100 Copay	$100 Copay	$100 Copay	$100 Copay
Urgent Care	$50 Copay	$50 Copay	$50 Copay	$50 Copay
In-Network Deductible & Coinsurance	$250 deductible per person, $500 per family, and 10% coinsurance up to $500 per person	$500 deductible per person, $1000 per family, and 10% coinsurance up to $750 per person	$100 deductible per person, $200 per family, and 10% coinsurance up to $250 per person	$350 deductible per person, $700 per family, and 10% coinsurance up to $500 per person
Out-of-Network Deductible & Coinsurance	$500 deductible per person, $1000 per family, and 20% coinsurance up to $1500 per person	$1000 deductible per person, $2000 per family, and 20% coinsurance up to $2250 per person	NOT COVERED	NOT COVERED
	Find a Horizon Provider		Find an Aetna Provider
	Prescription
	CAPITAL RX PLATINUM		CAPITAL RX GOLD
Tier 1 (Generic)	$5 Copay		$10 Copay
Tier 2 (Preferred)	$15 Copay		$20 Copay
Tier 3 (Non- Preferred)	50% with $30 Min./$50 Max		50% with $40 Min./$60 Max
Specialty	$100 Copay		$150 Copay
	For more information regarding your prescription coverage click here: Prescription Coverage Information
	Dental PPO
	Teamsters Health & Welfare PLATINUM		Teamsters Health & Welfare GOLD
	$2000 Annual Maximum per person		$2000 Annual Maximum per person
	PPO Dental Copayments:		PPO Dental Copayments:
Oral Surgery/Extractions	$25 per tooth		$25 per tooth
Endodontic surgery (Root Canal)	$25 per tooth		$25 per tooth
Periodontal surgery	$25 per quadrant		$25 per quadrant
Crowns, bridges, etc.	$30 per tooth		$30 per tooth
Partial/full dentures	$50 per unit		$50 per unit
Orthodontics (ages 10yrs-18yrs)	$100 per case (once per lifetime)		$100 per case (once per lifetime)
	Find Participating Providers
	Dental Non-PPO
	All services are paid based on Non-PPO fee schedule (click for fee schedule)
	Mental Health/Substance Abuse
	Horizon BCBS PPO PLATINUM	Horizon BCBS PPO GOLD	Aetna HMO PLATINUM	Aetna HMO GOLD
IN-NETWORK (Out-patient)	$20 copay	$30 copay	$20 copay	$30 copay
IN-NETWORK (In-patient)	$250 deductible per person, $500 per family, and 10% coinsurance up to $500 per person	$500 deductible per person, $1000 per family, and 10% coinsurance up to $750 per person	$100 deductible per person, $200 per family, and 10% coinsurance up to $250 per person	$350 deductible per person, $700 per family, and 10% coinsurance up to $500 per person
OUT OF NETWORK (In-Patient & Outpatient)	$500 deductible per person, $1000 per family, and 20% coinsurance up to $1500 per person	$1000 deductible per person, $2000 per family, and 20% coinsurance up to $2250 per person	$500 deductible per person, $1000 per family, and 20% coinsurance up to $1500 per person	$1000 deductible per person, $2000 per family, and 20% coinsurance up to $2250 per person
	Vision
	Vision benefits are provided by NVA. Please visit their website for a vast array of benefits. NVA Website
	Death Benefits
Death of Member	$20,000
Death of Spouse	$1,500
	Death of Dependent Child in accordance with age as follows:
Over 14 days, but less than six months	$300
Six months, but less than two years	$600
Two years, but less than three years	$1,200
Greater than three years	$1,500
	Accidental Death and Dismemberment Benefits (Members Only)
Loss of Life	$20,000
Both hands or both feet	$20,000
Sight of both eyes	$20,000
One hand and one foot	$20,000
One hand and sight of one eye	$20,000
One foot and sight of one eye	$20,000
One hand or one foot	$10,000
Sight of one eye	$10,000
	Unlike other plan benefits which are self-insured, these Death and Dismemberment Benefits are provided through a group life policy insured by Mutual of Omaha.
	Weekly Benefits
	$250 per week		$50 per workday
	If you work for a New Jersey Employer covered under the New Jersey Temporary Disabilities Law, you will receive 1/2 (half) of the disability payment indicated above. Disability benefits will commence on the first work day if the disability results from an accident or hospitalization. Benefits will commence on the sixth work day is the disability is a result of a sickness or pregnancy. Weekly disability benefits are payable for a maximum of 26 weeks. The Fund will pay you weekly disability benefits upon the initial denial of a worker's compensation claim if you execute a Fund approved subrogation agreement.

** All of the benefits noted on the following pages are subject to the eligibility schedule set forth in the Summary Plan Description

We have made every attempt to provide you with as much detail as possible as it relates to your benefits however, many of these benefits have limitations as well as pre-certification requirements. You should contact the Member Services Department at 1-800-523-2846 to discuss your particular situation and not rely solely on this website.